Eosinophilic oesophagitis and nutrition

Chapter 3.2
Eosinophilic oesophagitis and nutrition

Stephen E. Attwood and Stuart Allan

North Tyneside General Hospital, North Shields, UK

Eosinophilic oesophagitis (EoE) is an underrecognised chronic relapsing-remitting disease that is characterised by damage to the oesophageal mucosa by eosinophils. It can affect adults and children alike. In a large percentage of patients it presents as intermittent dysphagia but can cause severe social embarrassment, emergency admission to hospital, undernutrition and weight loss. It seems to have a strong link with atopy and many of the target therapies are similar to those used in asthma. Dietary omissions seem to play a strong role in the management of paediatric EoE and have a place in adult EoE but have limitations due to compliance. EoE is a very problematic condition but with careful input from a multidisciplinary team, good outcomes may be achieved.

3.2.1 Definition

Eosinophilic oesophagitis is a disease characterised by the presence of a large number of a special type of white blood cell, the eosinophil, that can cause inflammation in the oesophagus. It has recently been defined as ‘a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation’ [1]. Prior to 1990 it was very rarely recognised, and since then an increasing number of patients have been presenting throughout the Western world [2]. In the past many patients were assumed to have a variant of acid gastro-oesophageal reflux disease, but resistant to acid suppression therapy. Now it is recognised that EoE is not usually related to acid reflux and it does not usually respond to acid suppression therapy. The true prevalence of EoE remains unclear but it has been postulated that it may affect 400 per 100,000 people in the UK [3]. In children, it has been predicted that as many as 8.9 per 100,000 are affected [4], roughly the same number as in Crohn’s disease.

3.2.2 Typical symptoms

Eosinophilic oesophagitis manifestation is quite variable and begins at any age but is usually more common in younger males (M:F 3:1) [5]. The symptoms range in nature and severity. Dysphagia is the most common presentation and is largely intermittent but can be a continuous problem. In some, this intermittent dysphagia can present as an oesophageal food bolus obstruction requiring emergency attendance to hospital. For most, however, there is often severe social embarrassment as the patient attempts to relieve the obstruction. In children aged less than 9, regurgitation and failure to thrive are a common presentation. Unusual symptoms often prove a chronic element to the disease and are usually related to change in oesophageal structure. Dysphagia during every meal would suggest narrowing of the oesophagus either as a stricture to one part or a continuous narrowing of the oesophageal lumen. Weight loss and undernutrition may occur but only affect the most severe minority.

3.2.3 Diagnosis

A flexible endoscopy of the oesophagus with biopsy to look for the eosinophils in the mucosal lining is the essential test and should be done on everyone with unexplained swallow difficulties. Patients with assumed gastro-oesophageal reflux who do not respond to the usual acid suppression medications should also be examined by endoscopy and biopsy. A guideline of finding >15 eosinophils per high power field under the microscope is useful, although many patients have much higher densities of eosinophil infiltration. The endoscopy also identifies whether strictures, rings or other endoscopic abnormalities are present.

3.2.4 Natural history

Eosinophilic oesophagitis is a relapsing-remitting condition which is sometimes progressive over many years but in others remission can occur without relapse later. In adults, it is uncommon for symptoms to disappear without recurrence [6]. In children, the condition differs as some studies have shown that relapse can be prevented with successful dietary therapy [7,8].